7/27/2009

Is Attention-Deficit/Hyperactivity Being Overlooked?

A delve into the details of the disorder and how it applies to insurance claims resolution.

By Steven Carter, PsyD, LP

Claimants demand that insurers pay for a wide variety of mental disorders and neuropsychological impairments that were allegedly caused by an insured event. The equitable resolution of these claims requires that other explanations be excluded. One commonly overlooked possibility, particularly in adults, is Attention-Deficit/Hyperactivity Disorder. Believing that they have permanent brain injury when, in fact, they have a treatable mental disorder does not help claimants. Moreover, the financial compensation is wasted when it is spent on treatments for the wrong disorder.

 

A basic familiarity with the diagnostic criteria and types of ADHD will help in recognizing when it is potentially relevant to claims investigation. Although ADHD is a childhood developmental disorder, the symptoms frequently persist into adulthood. ADHD is not new and not just “acting badly.” It causes neuropsychological impairments that can easily be mistaken for signs of brain damage unless a careful analysis of the claimant’s history and childhood medical records is performed. It is frequently accompanied by comorbid mental disorders that can be mistakenly attributed to an insured event when, in fact, they are the result of living for years with ADHD.

 

DSM-IV-TR Diagnostic Criteria for ADHD
The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) contains the diagnostic criteria used in clinical settings. All of the DSM-IV-TR criteria must be present for a diagnosis of ADHD. For a valid diagnosis, a claimant must exhibit the core symptoms of attention problems, hyperactivity/impulsiveness, or both. It is also necessary that:
  • Symptoms are present in more than one setting, such as home, school, or work, or in more than one relationship (e.g., parents and grandparents in children, or spouse and coworkers in adults).
  • Symptoms result in significant impairment in educational, social, or occupational functioning.
  • The core problems have been present for at least six months
  • The problems began before seven years of age.
As yet, no medical screening tests, for example, electroencephalograms (EEGs), heavy metal concentration, thyroid, blood or organ imaging tests have proven to be useful as screening or diagnostic tools for ADHD. Their use should be dictated by specific medical indications, not by the possibility of ADHD.

 

Currently, Independent Medical Exam (IME) doctors must rely on rating scales and behavioral observations designed specifically for diagnosing ADHD. No other psychological, general intelligence, neuropsychological or personality tests are of proven value in the diagnosis of ADHD, but they might help exclude other mental disorders.

 

DSM-IV-TR Types of ADHD
Currently, the DSM system allows for the following diagnostic possibilities:
  • Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type
  • Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type
  • Attention-Deficit/Hyperactivity Disorder, Combined Type
  • Attention-Deficit/Hyperactivity Disorder, Not Otherwise Specified (NOS)
The NOS diagnosis is used for individuals whose symptoms and impairments meet the diagnostic criteria for Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type, but whose age at onset is seven years old or older. It can also be used for individuals with clinically significant impairment who present with inattention, but a behavioral pattern marked by sluggishness, daydreaming, and hypoactivity rather than hyperactivity. The NOS diagnosis can be used for adult claimants when it is impossible to establish onset before seven years of age.

 

ADHD Is Not New
Many people think of ADHD as the latest excuse for selfish and impulsive behavior. In fact, ADHD is not new. It was first described around the start of the 20th century but then was largely lost from view as theories of environmental causes became paramount in the 1920s and dominated into the late 1960s. Then there was a shift away from perceiving children’s problems as merely a reflection of parenting and other situational variables and towards stable “disorders” within the child, often with a contributing genetic or biological cause. The diagnosis of ADHD has been subjected to an enormous amount of scientific scrutiny regarding its reliability and validity as a disorder and the implications for etiology, treatment and prognosis. It has long been established as a legitimate mental disorder.

 

ADHD Is Not Just ‘Acting Badly’
Heredity is the largest determinant of who will get ADHD. Twin and family studies show that heredity accounts for about 50% of the variance. Children of a parent with ADHD have a 50% likelihood of having ADHD. Among affected children, 8% of biologic parents and only 2% of adoptive parents also had ADHD. The biologic families of ADHD children have high rates of alcoholism, mood disorders, and antisocial personality.

 

Ineffective parenting, bad neighborhoods, and other situational variables are not considered causes, but may exacerbate preexisting symptoms and genetic vulnerability.

 

Other potential etiologic factors for ADHD include low birth weight, birth trauma, childhood traumatic brain injury, fetal alcohol syndrome, heavy metal poisoning, deficiencies of minerals and vitamins, sleep apnea, and prenatal nicotine exposure.

 

ADHD Is a Developmental Disorder That Often Affects Adult Claimants
Most recent studies indicate that a majority of children with ADHD will show core symptoms at least through adolescence and about half of the time into adulthood. Approximately 4% to 5% of adults have ADHD, making it one of the most common psychiatric disorders.

 

Diagnosing ADHD in adult claimants can be difficult because many adults with ADHD have developed coping mechanisms and deny that their impairments exist. For example, a salesman takes pride in his heavy schedule of high-energy sales calls because they produce a lot of business, but he is tortured by his inability to sit still at home or even on vacation. Other adults with ADHD-caused hyperactivity choose careers where the impairment is practically part of the job description—emergency medicine physicians, professional cooks, or even many claims adjuster positions.

 

ADHD Looks Like Brain Damage
In the seventies, ADHD was called “minimal brain dysfunction,” and there is modern evidence that the old label was not far off the mark. An organic neurological disorder involving the frontal lobes and the basal ganglia in the brain also has experimental support.

 

Positron emission tomography (PET) scanning has demonstrated that adults with past and current histories of ADHD showed 8.1% lower levels of cerebral glucose metabolism than controls, with the greatest differences in the superior prefrontal cortex and the premotor areas. This can impair a claimant’s ability to plan, organize, pay attention to details and instructions, screen out irrelevant information, carry a plan through to completion, and avoid distractions.

 

Quantitative electroencephalography (QEEG) also reveals changes in people with attention deficits. Excessive cortical slowing in prefrontal midline areas, with a decrease in posterior beta activity, might indicate under arousal and partially explain why stimulant medications are safe and effective treatments for ADHD.

 

ADHD Causes Neuropsychological Impairments
A recent study combined the findings from 104 measures and 50 standardized tests across 24 studies to determine differences in the neuropsychological functioning of adults with and without ADHD. The largest differences were found for verbal memory, focused attention, sustained attention, abstract verbal problem solving, and working memory. Smaller effects were found for executive functions, visual memory, and visual problem solving. These results are consistent with the hypothesis that the inattention symptoms more so than the hyperactivity symptoms of this disorder persist into adulthood.

 

Signs That ADHD Should Be Considered in an Adult Claimant
Inattention
  • Difficulty completing tasks that require lengthy paperwork and reading
  • Ineffective time management
  • Difficulty finishing tasks (e.g., multiple partially repaired cars in yard, carpentry projects in house, or garden renovations)
  • Frequently loses forms related to claim
  • Forgets depositions and teleconferences
Hyperactivity
  • Talks excessively
  • Conspicuous finger tapping and foot jiggling
  • Risky and adventurous activities during leisure time
  • Occupation that requires a frenetic work pace (e.g., cook, ER physician, sales)
  • Depression that quickly passes when a specific difficulty is resolved
  • Ordinary pressures of life are experienced as repetitive and never-ending crises
Impulsivity
  • Intrudes on and interrupts others conversations and activities
  • Higher than average number of speeding citations, license suspensions, crashes, and crashes involving bodily injury
  • Failed attempts to complete vocational and college programs
  • Occupational achievement below expectations for intelligence
  • Impulsive job changes, major purchases, and long-distance moves
  • Interpersonal difficulties in multiple settings due to short-lived relationships or loss of control (e.g., multiple divorces, domestic violence charges)
  • Work and home tasks impetuously initiated without a plan for necessary materials, staffing and time
Other Commonly Seen Signs
  • Low self-esteem
  • Abuse of alcohol and other drugs
  • Heavy use of legal stimulants (e.g., caffeinated coffee, soda, “power” drinks, caffeine tablets)
  • Illegal stimulants (e.g., methamphetamine)
  • Use of illicitly acquired prescription stimulant medication (e.g., Ritalin, Adderall)
Childhood Medical Records Are Critical
Though the diagnosis of ADHD in adults depends on verifying that symptoms first appeared in childhood, obtaining childhood recollections and early records is difficult. Reviewing childhood medical and school records is critical. Attempts should be made in any case where an adult claimant is exhibiting the above signs of adult ADHD but alleging that the problems were caused by an insured event that occurred during adulthood.

Outside Observers Critical
Reports from persons familiar with the claimant (e.g., spouse, coworkers) will typically contain far more problems than the claimant will report. Outside observers will also often be the best sources of information about comorbid but non-proximally caused mental disorders that affect three of every four adults with ADHD. Mood disorders (major depression, bipolar disorder, and dysthymia), anxiety disorders, substance abuse, personality disorders and learning disabilities are the chief psychiatric comorbidities. Outside observers and pre-morbid medical records will often indicate evidence that signs and symptoms of these disorders long predated the insured event and followed a waxing and waning course that was not appreciably altered by proximally caused injuries.

The recent reckless behavior of a claimant in the manic phase of bipolar disorder, a claimant with ADHD, and a claimant with impulsivity due to brain damage are nearly impossible to distinguish without the benefit of extended observation by outside observers. Dysthymia, a form of low level depression that lasts at least two years, could be unconnected with the claimant’s undiagnosed ADHD or be the result of living for years with its frustrations. Substance abuse can be the claimant’s way of coping with ADHD symptoms of restlessness and hyperactivity or a way of coping with the trauma of an insured event.

A longitudinal history supplied by outside observers is helpful in assigning the symptoms to the appropriate cause. ADHD symptoms usually are lifelong and less episodic than are those of comorbid disorders.
 


Steven Carter, PsyD, LP, is CEO of Clarius Health, which provides medical evidence analysis, independent examinations and testimony nationwide. He has been a CLM Fellow since 2011 and can be reached at steven@clariushealth.com or (218) 305-4588, www.clariushealth.com.

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